Firefighters & First Responders In Need of Treatment

The Treatment Needs of Our Firefighters & First Responders

Addressing Mental Health & Substance Abuse

Treatment Experts on the Latest Research, Best Practices and Treatment Options – October 2015

Resource Sections
Mental Health Issues
Barriers to Treatment
Treatment Today
Journey to Recovery

For firefighters and first responders, maintaining optimum mental wellness is a critical part of remaining active and effective on the job as well as at home. Constant exposure to trauma, life-threatening situations, and the physical strain of working long hours on little to no sleep can negatively impact overall mental health, increasing the vulnerability and risk of substance abuse and addiction among firefighters and first responders.

It’s important to note, too, that there are various aspects of the job that can contribute positively to mental health. These include:

Positive relationships with coworkers
Meaningful and important work
Productive and/or positive atmosphere in the workplace
Livable wages and benefits

Finding balance when the negative issues begin to outweigh the positive is essential to maintaining optimum mental health.

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“Because of the extreme things we see in our everyday line of duty…It’s easy to develop an ‘us-and-them’ attitude. It’s very tempting to want to stay with those who understand – and soon family and friends can even be excluded. We have to watch out for that.”

— Retired Fire Captain Michael Morse

Sometimes it takes conscientious effort to maintain positive relationships with friends and family members.

This Article Was Reviewed By:

James Morrison, CADC

Retired Chicago Police Officer/EAP

AAC Treatment Cons. – Law Enforcement

Michael Blackburn, CEAP, LADC-1, SAP

Retired Providence Fire Dept. Battalion Chief, RI

Sr. Vice President, Business Development

Michael Healy, CEAP, SAP, LAP-C

Fire Chief, Central Nyack Fire Dept, NY

AAC Treatment Cons. – Fire Service

Culture and Mental Health Treatment in American Society

In the United States, treatment of all mental health disorders is essentially based on scientific research and evidence that is objective and repeatable. The self-correcting process that comes with new and diversified research methods, the peer review of findings, and the transparency of research provided through publication in journals not only help to spread awareness of new and updated treatments but also demonstrate the differences among patients when exposed to different treatments and/or combinations of treatments in different contexts.

Because the United States is a melting pot of cultures, it becomes important then to discuss the significant impact that an individual’s culture and personal experience not only has on the development of mental health symptoms but on one’s willingness and ability to seek treatment, follow through with treatment, and benefit from the treatment services commonly applied to the care of different diagnoses.

“Culture” includes the views, beliefs, and values that an individuals holds as “normal” and can impact the experiences and choices of the client, the client’s family and community, the clinician, as well as the body of work informing treatment. Additionally, other cultural issues – such as gender, race, economic status, professional culture, religious views, and more – may contribute to an increased or decreased ability to access and benefit from different mental health treatment models or to work effectively with different clinicians. It’s important to take all these issues into consideration when determining the best course of action for treatment.

In the worlds of first responders, culture can play a significant role in whether or not those in need reach out for help or even recognize that the symptoms they are dealing with are in fact a disorder that requires care and treatment.

The Stigma of Mental Illness in the US

The 2007 Behavioral Risk Factor Surveillance System (BRFSS) by the Centers for Disease Control (CDC), suggest that the stigma against those who are living with mental illness is a significant issue in the United States. For example, only 24.6 percent of participants who were living with mental health symptoms thought that people would care about their struggle. Fortunately, this same study found that 57.3 percent of respondents who were not struggling with mental health symptoms believed that people were sympathetic to the issue. These survey results could be interpreted as those with mental health issue mistakenly underestimate the overall sympathetic nature of the general population when it comes to those suffering from mental health issues.

Furthermore, the study also found that almost 77.6 percent of people living with mental health symptoms and almost 88.6 percent of those not living with mental health issues believed that treatment could assist in helping the person to live a balanced and “normal” life. These survey results could be viewed as showing an overwhelming consensus that treatment is a good thing.

What do these findings suggest? Possibilities include:

Lower rates of people in need of treatment seeking help due to fear of being judged by others
Increased self-judgment and incidences of depression and low self-esteem among those living with mental health symptoms
Increased attempts to self-medicate mental health symptoms through drugs and alcohol rather than seeking treatment
Decreased likelihood that family members will admit that the struggles of a family member are signs of anything more than a passing phase or “normal,” especially among first responders given the nature of the job
Less support for people in recovery from mental illness (e.g., professionally, among peers, in the community, etc.)

The Substance Abuse and Mental Health Services Administration (SAMHSA) among other mental wellness agencies is working to decrease stigma in the United States by dispelling myths and increasing awareness of the personal experience of those living with different mental health symptoms. One way in which SAMHSA is working to increase compassion and support for those living with mental health symptoms is by advocating for the development of peer support and social inclusion services for individuals and their families. These services seek to:

Increase understanding of addiction and other mental health disorders
Provide people in recovery for mental health issues with a forum to safely share about their experiences
Provide people in recovery and their families a place to connect with others who are living with similar issues
Allow the public to step forward, offer support, and share their experiences

For firefighters, first responders, and their families, the stigma against mental health issues can be an obstacle to treatment. Not wanting to call attention to their struggle and preferring instead to focus on the job, many in the profession do not want to acknowledge that they might be in need of treatment or that their symptoms may be complicating their ability to function physically and/or mentally.

“In the mid 80’s NFPA 1500 mandated that each department have a Members Assistance Program…So if anything, they were ahead of the curve.”

— Chief Michael A. Healy, addiction specialist and former chief fire instructor of American Addiction Centers

The organization that writes standards for firefighter safety – NFPA – gave behavioral health a distinct chapter in 2013. And the organization generally leads the charge in taking proactive measures to ensure firefighter safety.

NFPA.Org

This indicates that while preventative behavioral health has taken a while to gain broad scale traction, things are changing for the better.

An upsurge in prevention and education efforts across support organizations for active firefighters and first responders as well as retired veterans, including organizations like the National Fire Protection Association, has helped to increase awareness of how common mental health issues may be among first responders and firefighters. It has also improved access to appropriate care and treatment.

Common Mental Health Issues Identified Among First Responders

Law enforcement officers, firefighters, paramedics, and other first responders must continually see the worst of human experience. The ravaging effects of fire, the emotional and physical damage caused by accident and abuse, the threat of personal attack, constant stress, and an inability to save everyone they attempt to help take a toll.

Additionally, long shifts, working with others who are similarly struggling with mental health disorders, difficulties at home, and other personal issues can all contribute to the high rates of the mental health disorders commonly diagnosed among first responders.

Furthermore, retirement can uncover or exacerbate alcohol, drug, and mental health disorders that may have been masked or submerged during active duty.

Dr. Ralph Tenney, a therapist who works with law officers at American Addiction Centers, sees the period right after retirement as a vulnerable time for first responders. Submerged emotional issues suddenly become amplified; self-medicating tendencies run amok. Tenney says that retired first responders have a window, about a year-and-a-half, to make a healthy transition from active duty. Typically it involves refocusing on new interests and finding fulfillment apart from the force or the department.

First responders who have trouble making the transition are even more vulnerable to the host of mental health disorders that target first responders, such as:

PTSD
Anxiety
Depression
Substance Abuse
Co-occurring Disorders

Post-traumatic stress disorder (PTSD): There are different manifestations of PTSD, and not all people who may be living with the disorder will exhibit the same symptoms. Exposure to significant trauma – like the experiences that could happen on any given shift for a first responder – are known to trigger the different types of PTSD. According to the National Institute of Mental Health (NIMH), the three types include:

Re-experiencing: Overwhelming fears, unexpected flashbacks of trauma events that include the same rapid breathing and sweating originally experienced, nightmares, and other intrusive symptoms characterize this type of PTSD.
Hyperarousal: Often feeling on edge, intense anger response, insomnia, and/or being easily startled are all signs of hyperarousal.
Avoidance: Feelings of guilt and depression (or having no feelings of attachment at all), difficulty remembering traumatic events, lack of interest in former hobbies, and avoiding places that trigger memories of trauma are all signs of avoidance.

Anxiety: Anxiety symptoms that last for six months or more generally qualify for a diagnosis of generalized anxiety disorder (GAD), social anxiety disorder, panic disorder, obsessive-compulsive disorder (OCD), or phobia. The specific symptoms will vary depending upon the disorder but may include intense fears of specific places or things, obsessive thoughts that are intrusive, disrupted sleeping and eating patterns, substance abuse, and more.

Depression: Though everyone may occasionally get the blues, or feel sad or down about a specific event or problem in their lives, first responders often suffer from ongoing and deep feelings of hopelessness, loss, suicidal thoughts and behaviors, guilt, insomnia, and other issues related to the disorder. Depression can be diagnosed as mild (dysthymia), moderate, or severe, or it can be a symptom of another mental health disorder like post-traumatic stress disorder (PTSD). It can also be worsened or driven by substance abuse and addiction.

Substance abuse and addiction: Addiction to drugs or alcohol is defined by compulsive use of the drug (or drugs) of choice despite the negative consequences that result. It is a chronic disease that causes physical and discernible changes in the brain and thus in the person’s mental and physical health and personality. People who are diagnosed with addiction will be unable to stop using or drinking on their own and require professional detox and addiction treatment.

Co-occurring disorders: When people are living with both drug or alcohol dependence disorder and a diagnosed mental health condition, they are diagnosed with co-occurring disorders. The two issues often significantly impact one another, making it difficult to impossible to treat one disorder without also comprehensively treating the other. For example, those who struggle with anxiety and who use drugs and alcohol to calm their fears may not benefit from stopping the use of drugs of alcohol for long if they are not given the coping mechanisms they need to manage their anxiety issues without feeling the urge to drink or get high.

Firefighters, First Responders, and Law Enforcement Have High Rates of Mental Health Disorders

The Substance Abuse and Mental Health Services Administration (SAMHSA) reports that about one in five adults – or 43.8 million Americans – in the United States was living with a diagnosable mental health disorder in 2013. Additionally, they found that about 9.3 million Americans considered taking their own lives that year. These are numbers that resemble reports from 2012.

First responders, including law enforcement and firefighters, are certainly part of this statistic, but unfortunately, as compared to the general public, there are often higher rates of mental illness, including substance abuse, addiction, and suicide.

Every year, new lists are released highlighting the professions most commonly linked to specific mental health disorders, including substance abuse and addiction. In addition to first responders, included on this list are often:

Lawyers and judges
Doctors and other medical professionals
Military personnel
Chemists
Real estate and sales professionals

Electricians
Financial services
Farmers
Transportation and public utilities
Food services workers

Police officers are often included in these top 10 lists but rarely are firefighters, paramedics, and EMS workers despite the evidence that these professions often suffer great loss due to suicide and experience high rates of mental health disorders. For example:

The Firefighter Behavioral Health Alliance notes that 105 firefighters took their own lives in the United States in 2014. Because this number is based on reported suicides, actual numbers may be higher.
The US Firefighters Association (USFA) reports that about 10 percent of firefighters may be abusing illicit substances and that alcohol abuse among this population is more than twice the rates seen in the general public.
Post-traumatic stress disorder, depression, and suicidal thoughts and behaviors among first responders are also common and believed to be triggered or worsened by repeat exposure to trauma, including physical abuse and death among the people they serve, loss of people close to them, and life-threatening situations.

Perceived Barriers to Treatment

There should be nothing stopping people who struggle with a mental health disorder or substance abuse issue from connecting with treatment that will help them to change their lives. Unfortunately, there are often perceived barriers cited by people living with these disorders that may postpone them getting the help they need. Firefighters and other first responders are often deeply impacted by these issues.

Some commonly cited reasons for avoiding treatment or denying the need for treatment include:

When people recognize that there are changes – negative changes – that have occurred in their lives and relationships due to their substance abuse or mental health issues, it is hard to deny that treatment is needed. The simplest way to avoid having to contemplate change and what that would look like – and often the biggest barrier to treatment – is to simply deny there is a problem.Denial is not just personal. People in denial will often work hard to cover up their use of drugs/alcohol and do the same thing with their mental health symptoms to avoid addressing issues. This makes it more difficult for others to recognize the problem in its early stages or to see how serious the issue is so they can turn the focus toward getting necessary treatment.

Firefighter and law enforcement cultures and first responder work environments are not particularly conducive to the exploration of “feelings.” These are tough jobs, and there is the perception that people need to be tough to do them. Though it is recognized that people on the job may struggle with the dangers they have to deal with every day and things they have seen in the line of duty, it is not always readily acceptable to discuss it openly or to admit the need to talk to someone about it on the therapeutic level. Rather than deal with the stigma against working through, for example, post-traumatic stress disorder related to the job, first responders may instead drown the experience at the bar or use other drugs in an attempt to escape – not only avoiding treatment that can help them but also inadvertently developing a second disorder that is equally debilitating.

Many first responders believe that if they discuss their issues with post-traumatic stress, depression, anxiety, and substance abuse that they will put their jobs at risk. In most cases, this fear is unfounded. In fact, the earlier people get help, the more likely they will be stabilize more quickly and return to work more functional than before. Unfortunately, avoiding treatment for a serious mental health condition including addiction will almost certainly result in job loss when the issues related to that disorder cause the person to make deadly mistakes on the job. These mistakes often reveal the problem as well as its depth and severity at the worst possible time and in the most public way. In addition, the mistakes put coworkers and the people being served at risk.

In addition to the above concerns about how people at work may respond to the admission that a mental health symptom, experience of trauma, or substance abuse disorder has become an unmanageable issue that requires treatment, many first responders fear the response of the community at large. They may not want to admit to their family at home or to extended family members that they are struggling, and they have concerns that they may be treated differently as a result. They may also be concerned that others in the community – people they serve – may find out or know about their health issues and that will affect their ability to take charge of situations when necessary. Again, however, the stigma against choices made under the influence, or choices that put others in emotional or physical harm’s way caused by untreated mental health issues and addiction, is far worse and more difficult to overcome.

Many continue to live with disruptive mental health and substance abuse issues because they mistakenly believe that there will be no benefit to getting treatment. Rather than risk issues of stigma or job loss, they characterize what they are living with as unavoidable and continue to try to deal with it on their own.

Some treatment programs can be expensive, but everyone has access to affordable health insurance coverage that will help to bear the brunt of the cost of treatment services for mental health issues as well as substance abuse and addiction. Additionally, many first responders are afforded increased care and coverage for the treatment of issues that occur on the job.

Many believe that there are few treatment resources in their area or that waiting lists are too long to make it worthwhile to apply. There are, however, numerous in-state and out-of-state treatment options available. While some have the benefit of offering nearby outpatient treatment services, others provide increased confidentiality protection and anonymity by putting some physical distance between the person’s home and the place of recovery.

Mental Health Treatment Today

There are numerous options available in mental health treatment services for all types and combinations of symptoms. The issue may be a commonly diagnosed mental health disorder like depression or anxiety, or symptoms of depression and anxiety may be indicative of a personality disorder, post-traumatic stress disorder, or another complex illness. Mental health issues may be exacerbated by drug and/or alcohol abuse or addiction.

Regardless, there is a range of inpatient and outpatient treatment services that are available. Each person who enters treatment should begin with a complete diagnostic evaluation in order to facilitate the creation of a unique treatment plan designed to connect with the services that will be most beneficial to the individual’s needs.

With the increasing need for the treatment industry to grow, more options are becoming available – and with the understanding that the needs of each individual in recovery is unique, there should be a right plan for all.

Additionally, the Affordable Care Act has improved the ability of insurance holders to get coverage for medical and therapeutic care for mental health issues, including substance abuse and addiction.

The Need for Treatment

When mental health symptoms increase in severity and continue for months on end, and when substance abuse becomes a chronic problem and begins to impact the person’s ability to function in everyday life, none of the perceived issues above that could potentially justify avoiding treatment are valid any longer. When is it time for treatment?

Signs that help is necessary include:

Increased arguments at home with a spouse or significant other due to choices made under the influence or the impact of changes caused by mental health symptoms and/or drug and alcohol abuse
Difficulties at work that range from showing up late or calling in sick to being unable to function at optimum levels due to issues related to substance abuse and mental health
Health problems related to mental health symptoms or drug abuse (e.g., insomnia, poor eating habits, and chronic illnesses related to the drug or drugs of choice, or an inability to manage underlying medical issues)
Mental health issues that impact others, including changes in personality or extreme/violent mood swings
Any choices related to substance abuse (e.g., drinking and driving) or ongoing mental health symptoms (e.g., suicidal behaviors, violent outbursts) that put the person or others at risk.

The Process of Recovery

Each person should have a unique experience in treatment and recovery just as each person had a unique experience that led up to the need for treatment. There is, however, a general structure that is often utilized to make sure each client who enters treatment is connected with the services and support necessary to make efficient and steady progress in recovery.

Stabilization

Some people wait until they are in the midst of medical and/or mental health crisis before they begin treatment. In these cases, the first order of business is stabilization. Urgent medical care to manage acute medical issues like overdose and/or any injuries incurred due to accident or self-harm will be addressed first with stabilization as the goal.

Medical detox

In the case of addiction, some clients will experience physical and mental health withdrawal symptoms during the first days and weeks of recovery. If this is the case, medical care is available via pharmacological assistance, therapeutic support, and medical treatment if necessary to ensure that this process is as safe and swift as possible.

Evaluation and diagnosis

Once stabilized, the client can undergo appropriate evaluation in order to obtain a diagnosis or diagnoses that pinpoint the driving force underlying the symptoms experienced.

Treatment plan

Based on the findings of the evaluation process, each client will have developed a unique treatment plan that incorporates a range of treatment services and resources to address symptoms. In addition, the plan will provide the client with coping mechanisms that will enable the ability to learn how to self-manage the disorder or disorders independently.

Traditional Therapy

Most treatment programs are based upon traditional models of care in recovery, including the 12-Step program as well as cognitive and behavioral therapies provided on a one-on-one basis. Additionally, a range of support group options is often made available that may center on a specific need shared by the group or may simply offer participants a chance to work on different coping mechanisms.

Alternative Options

A range of alternative treatment options exists to help clients explore issues and possible coping mechanisms for stress and trauma outside of verbalization. Active and interactive therapies like outdoor and adventure therapies, nutritional therapy, sports therapies, and others can provide first responders with more physical ways of regaining confidence and self-esteem and rebuilding connections with others.

Holistic Treatment

Learning how to lower overall levels of stress can significantly contribute to a person’s ability to manage acute stressors on the job. By using holistic methods, such as meditation, exercise, massage, yoga, and others, clients can explore different options until they find a combination of resources that works for them.

Family Support

Family members often struggle just as deeply as the person living with mental health issues and drug/alcohol abuse or addiction. As a result, family members require their own comprehensive care and treatment programs. Connecting with other family members who are experiencing the same issues in their families can provide a sense of support and community that breaks down the commonly experienced feelings of isolation and desperation that come with untreated mental health and addiction issues.

Aftercare Services

The cessation of formal treatment is not the end of recovery but the beginning of life defined by the new principles learned in treatment. In order to sustain these new lifestyle choices, it is important to remain actively engaged in the recovery community and connected to appropriate treatment services. Personal therapy, 12-Step meetings or other support group sessions, family counseling, and alternative or holistic treatment choices are recommended.

No matter what treatment resources are chosen, prospective clients can rest assured that their experiences in treatment – and even the fact that they underwent treatment and why – will remain completely confidential. Though in some cases it may be helpful to have a frank discussion with employers in order to manage certain issues related to the job or to ensure that the job will still be available when treatment is over, no details need ever be shared on any level unless the client makes the decision to discuss those details. Anonymity and confidentiality are huge components of treatment and part of why it can be so effective.

The Journey Toward Recovery

Making the choice to enter mental health treatment, even when the need for treatment services is quite clear, isn’t always a straightforward process. It can take time, reflection, and a few false starts before treatment begins in earnest. Often, family members and concerned friends and coworkers may be called upon to aid in that process by staging an intervention.

“Everyone in the department knows who has a drinking problem…In some departments, they may not talk about it, and unless there’s some kind of awareness program, they are even less likely to talk to the drinker directly. But you’ll know they know – you start getting shadowed on a run; conversation drops off when you walk in a room. At that point, the problem is no longer anyone’s secret.”